The Impact of Dual-Tasks and Disease Severity on Posture, Gait, and Functional Mobility among People Living with Dementia in Residential Care Facilities: A Pilot Study.

Gait speed and timed-up-and-go (TUG) predict cognitive decline, falls, and mortality. Dual-tasks may be useful in cognitive screening among people living with dementia (PWD), but more evidence is needed. This cross-sectional study aimed to compare single- and dual-task performance and determine the influence of dementia severity on dual-task performance and interference. Thirty PWD in two residential care facilities (Age: 81.3 ± 7.1 years; Montreal Cognitive Assessment: 10.4 ± 6.0 points) completed two trials of single- (feet apart) and dual-task posture (feet apart while counting backward), single- (walk 4 m) and dual-task gait (walk 4m while naming words), and single- (timed-up-and-go (TUG)), and dual-task functional mobility (TUG while completing a category task) with APDM inertial sensors. Dual-tasks resulted in greater sway frequency, jerk, and sway area; slower gait speed; greater double limb support; shorter stride length; reduced mid-swing elevation; longer TUG duration; reduced turn angle; and slower turn velocity than single-tasks (ps < 0.05). Dual-task performance was impacted (reduced double limb support, greater mid-swing elevation), and dual-task interference (greater jerk, faster gait speed) was related to moderate-to-severe compared to mild PWD. Moderate-to-severe PWD had poorer dynamic stability and a reduced ability to appropriately select a cautious gait during dual-tasks than those with mild PWD, indicating the usefulness of dual-tasks for cognitive screening.

A Moratorium on the Euphemism MAID.

It is essential for high-quality health care for providers to adhere to the principle of truth telling, speaking with clarity and honesty. The euphemism medical aid in dying, MAID, is being mainstreamed in the medical literature by proponents of physician-assisted suicide and euthanasia. This trend is deleterious because MAID's proponents do not consistently express the meaning and intent of the practice, and the phrase downplays the fact that a provider is participating in the act of death for a patient. The euphemism blurs the differences between providing high-quality palliative care and participating in the death of a patient prior to a natural death. Some believe the term MAID is used exclusively for assisted suicide in patients with a terminal diagnosis with less than 6 months to live, when in fact it is being used for both assisted suicide and euthanasia and for patients who have no terminal diagnosis with potentially years to live. We are calling up on our colleagues to cease the use of this and other euphemisms in this ethically controversial practice. We recommend standardized language that accurately denotes the context and process. Provider Assisted Death by Prescription (PAD-P) and Provider Assisted Death by Administration (PAD-A) are terms that most accurately describe the process, taking into account who is prescribing or administering a lethal substance and the outcome of the actions. Literature that addresses this practice should be described as ending life literature. The standardized language needs to be used on death certificates so we can most accurately assess the impact that provider-assisted death is having on society. Emphasizing truth telling in morally controversial practices will foster trust among health care providers and with patients.

Exploring the Association Between Physical Activity and Cognitive Function Among People Living with Dementia.

Background: Physical activity preserves cognitive function in people without dementia, but the relationship between physical activity and cognitive domains among people living with dementia is unclear. Objective: The objective of this study was to explore the association between physical activity and cognition domains among people living with dementia. Methods: Participants living with dementia in residential care facilities (complete case analysis: n = 24/42) completed a battery of cognitive tests (global cognition: Montreal Cognitive Assessment; executive function: Trail-Making Test, Digit Span Forward Test; perception and orientation: Benton Judgement of Line Orientation Test; language: Boston Naming Test; learning and memory: Rey Auditory Verbal Learning Test; complex attention: Digit Symbol Substitution Test). Participants wore an actigraphy monitor on their non-dominant wrist over seven days. We conducted a linear regression for total physical activity (independent variable) with race (white/black), fall risk (Morse Fall Scale), and the number of comorbidities (Functional Comorbidities Index) as covariates, and cognitive tests as variables of interest. Results: Participants were primarily male (75%), white (87.5%), and 50%had unspecified dementia (Alzheimer's disease: 33%). Greater physical activity was associated with poorer global cognition, better executive function, and better learning and memory (ps <  0.05). Physical activity was not related to visuospatial perception, language, or complex attention. Conclusions: Physical activity may preserve executive function and learning and memory among people living with dementia. Wandering is more common in later stages of dementia, which may explain greater physical activity observed with lower global cognition. Regularly assessing physical activity may be useful in screening and monitoring cognitive changes.

The effects of strEngth aNd BaLance exercise on Executive function in people living with Dementia (ENABLED): Study protocol for a pilot randomized controlled trial.

BACKGROUND: Exercise may improve executive function among people living with all-cause dementia (PWD), but more evidence is needed. The aim of this pilot randomized controlled trial (RCT) is to examine whether exercise plus usual care improves the primary outcome of executive function, and secondary physiological (inflammation, metabolic aging, epigenetics) and behavioral (cognition, psychological health, physical function, and falls) outcomes compared to usual care alone among PWD. METHODS AND STUDY DESIGN: The strEngth aNd BaLance exercise on Executive function in people living with Dementia (ENABLED) protocol is a pilot parallel, 6-month assessor-blinded RCT (1:1) in residential care facilities, including n = 21 receiving exercise plus usual care and n = 21 usual care alone [NCT05488951]. We will collect primary (Color-Word Stroop Test) and secondary physiological (inflammation, metabolic aging, epigenetics) and behavioral (cognition, psychological health, physical function, and falls) outcomes at baseline and 6 months. We will obtain falls monthly from medical charts. We will collect physical activity, sedentary behavior, and sleep via wrist-worn accelerometers over 7 days at baseline and 6 months. The physical therapist-led adapted Otago Exercise Program will involve 1-h of strength, balance and walking 3×/week for 6 months in groups of 5-7. We will use generalized linear mixed models to examine differences over time in primary and secondary outcomes between groups and examine potential interactions with sex and race. DISCUSSION: This pilot RCT will examine the direct effects and potential underlying physiological mechanisms of exercise on executive function and other behavioral outcomes in PWD, which may have implications for clinical care management.

The Secret of Quality Is Love: A Qualitative Study Exploring Physician and Nurse Perspectives on What It Means to Love Their Patients.

Little research systematically explores healthcare professionals' understanding of what it means to love their patients. The authors hypothesized that nurses and physicians would describe a language of love relevant to health care. Researchers conducted structured interviews with 29 physicians and 32 nurses at an academic medical center through a combination of purposive, convenience, and snowball sampling. Interviews were transcribed verbatim and analyzed using grounded theory, identifying major themes from qualitative data. Most nurses and physicians declared they should love their patients. Characteristics of loving physicians and nurses included caring, clinical excellence, advocating, meeting needs, compassion, sacrifice, and tough love. Moral imperatives included the duty to act on behalf of the patient's best interest, respect the patient's wishes, treat patients as you would want your family treated, and recognize limits of life. Many physicians and nurses commented that loving patients could transform health care. Physicians and nurses described characteristics and imperatives of love that may serve as an ethical standard for healthcare professionals.

Medical student reflections: Chaplain shadowing as a model for compassionate care training.

PURPOSE: Training of compassionate and empathetic physicians requires commitment by educators to make it a priority. Chaplains typically have time and training to effectively demonstrate compassionate care in the clinical setting. This qualitative study aims to explore perceived benefits among medical students from pastoral care shadowing in integrating compassion and spirituality into education curricula. METHODS: Sixty-four written reflections from first- and second-year medical students were collected from December 2018 to January 2020 after shadowing with hospital chaplains. Unprompted reflections were analyzed using coding networks. RESULTS: Four major themes identified included (1) learned values within pastoral care, (2) learned roles of pastoral care in the healthcare setting, (3) practiced spiritual assessment tools and resource identification, and (4) reflected personal impact on future career. Within each major theme, three to four sub-themes were further identified. CONCLUSIONS: Reflections support chaplain shadowing as a model for emphasizing spiritual and compassionate care through role-modeling, hands-on learning and reflective practices.

An interprofessional cohort analysis of student interest in medical ethics education: a survey-based quantitative study.

BACKGROUND: There is continued need for enhanced medical ethics education across the United States. In an effort to guide medical ethics education reform, we report the first interprofessional survey of a cohort of graduate medical, nursing and allied health professional students that examined perceived student need for more formalized medical ethics education and assessed preferences for teaching methods in a graduate level medical ethics curriculum. METHODS: In January 2018, following the successful implementation of a peer-led, grassroots medical ethics curriculum, student leaders under faculty guidance conducted a cross-sectional survey with 562 of 1357 responses received (41% overall response rate) among students enrolled in the School of Medicine, College of Nursing, Doctor of Physical Therapy and BS/(D) MD Professional Scholars programs at The Medical College of Georgia at Augusta University. An in person or web-based questionnaire was designed to measure perceived need for a more in-depth medical ethics curriculum. RESULTS: The majority of respondents were female (333, 59.3%), white (326, 58.0%) and mid-20s in age (340, 60.5%). Almost half of respondents (47%) reported no prior medical ethics exposure or training in their previous educational experience, while 60% of students across all degree programs reported an interest in more medical ethics education and 92% noted that an understanding of medical ethics was important to their future career. Over a quarter of students (28%) were interested in pursuing graduate-level training in medical ethics, with case-based discussions, small group peer settings and ethics guest lectures being the most desired teaching methods. CONCLUSIONS: The future physician, nursing and physical therapist workforce in our medical community demonstrated an unmet need and strong interest for more formal medical ethics education within their current coursework. Grassroots student-driven curricular development and leadership in medical ethics can positively impact medical education. Subsequent integration of interprofessional training in medical ethics may serve as a vital curricular approach to improving the training of ethically competent healthcare professionals and overcoming the current hierarchical clinical silos.

A logic framework for evaluating social determinants of health interventions in primary care.

BACKGROUND: Increasing efforts have been made in primary care settings to screen for a broad array of social determinants of health including inadequate food and nutrition, lack of education, unemployment, and inadequate housing, and to refer patients to community resources. Core tenets of primary care include integration with community resources. METHODS: In the course of designing a randomized controlled trial of the effectiveness of a social determinants of health intervention aimed at adult, at-risk, African American primary care clinic patients, our research team developed a logic model to assist with the evaluation of the intervention. RESULTS: In this article, we describe the logic model including elements of the intervention, mediator variables, and outcome variables. CONCLUSIONS: The proposed logic framework is likely to be helpful for planning, conducting, and evaluating social determinants of health interventions in primary care settings.

Hepatitis B: Screening, Prevention, Diagnosis, and Treatment.

Hepatitis B virus (HBV) is a partly double-stranded DNA virus that causes acute and chronic liver infection. Screening for hepatitis B is recommended in pregnant women at their first prenatal visit and in adolescents and adults at high risk of chronic infection. Hepatitis B vaccination is recommended for medically stable infants weighing 2,000 g or more within 24 hours of birth, unvaccinated infants and children, and unvaccinated adults requesting protection from hepatitis B or who are at increased risk of infection. Acute hepatitis B is defined as the discrete onset of symptoms, the presence of jaundice or elevated serum alanine transaminase levels, and test results showing hepatitis B surface antigen and hepatitis B core antigen. There is no evidence that antiviral treatment is effective for acute hepatitis B. Chronic hepatitis B is defined as the persistence of hepatitis B surface antigen for more than six months. Individuals with chronic hepatitis B are at risk of hepatocellular carcinoma and cirrhosis, but morbidity and mortality are reduced with adequate treatment. Determining the stage of liver disease (e.g., evidence of inflammation, fibrosis) is important to guide therapeutic decisions and the need for surveillance for hepatocellular carcinoma. Treatment should be individualized based on clinical and laboratory characteristics and the risks of developing cirrhosis and hepatocellular carcinoma. Immunologic cure, defined as the loss of hepatitis B surface antigen with sustained HBV DNA suppression, is attainable with current drug therapies that suppress HBV DNA replication and improve liver inflammation and fibrosis. Pegylated interferon alfa-2a, entecavir, and tenofovir are recommended as first-line treatment options for chronic hepatitis B.

Blast-related mild traumatic brain injury in the acute phase: acute stress reactions partially mediate the relationship between loss of consciousness and symptoms.

PRIMARY OBJECTIVE: The objective was to compare symptoms in service members diagnosed with a blast-related mTBI (mild traumatic brain injury) with a loss of consciousness (LOC) to those without LOC. RESEARCH DESIGN: Clinicians saw US military personnel within 72 hours of sustaining a blast-related mTBI and at a follow-up visit 48-72 hours later (n = 210). METHODS AND PROCEDURES: Demographics, post-concussive symptoms, diagnosis of acute stress reaction (ASR) and simple reaction time data from the Automated Neuropsychological Assessment Metric (ANAM) were collected. MAIN OUTCOMES AND RESULTS: ASRs were significantly more likely in patients reporting LOC versus patients reporting no LOC. At the first post-injury visit, LOC was associated with difficulty sleeping, hearing loss, memory problems and reporting more symptoms. A follow-up analysis explored if symptomatic differences were influenced by ASR. Adjusting for ASR, the statistical relationships between LOC and symptoms were weaker (i.e. reduced Odds Ratios). At the follow-up visit, difficulty sleeping was associated with LOC before and after adjusting for ASR. Patients with both ASR and LOC had the slowest simple reaction times. CONCLUSIONS: Results suggest ASR may partially mediate symptom presentation and cognitive dysfunction in the acute phase following blast-related mTBI. Future research is warranted.

ANAM4 TBI reaction time-based tests have prognostic utility for acute concussion.

The Concussion Restoration Care Center has used the Automated Neuropsychological Assessment Metrics version 4 Traumatic Brain Injury (ANAM4 TBI) battery in clinical assessment of concussion. The study's aim is to evaluate the prognostic utility of the ANAM4 TBI. In 165 concussed active duty personnel (all ultimately returned to duty) seen and tested on the ANAM4 TBI on days 3 and 5 (median times) from their injury, Spearman's ρ statistics showed that all performance subtests (at day 5) were associated with fewer days return-to-duty (RTD) time, whereas concussion history or age did not. Kruskal-Wallis statistics showed that ANAM4 TBI, loss of consciousness, and post-traumatic amnesia were associated with increased RTD time; ANAM4 TBI reaction time-based subtests, collectively, showed the largest effect sizes. A survival analysis using a Kaplan-Meier plot showed that the lowest 25% on the reaction time-based subtests had a median RTD time of 19 days, whereas those in the upper 25% had a median RTD time of approximately 7 days. Results indicate that until validated neurocognitive testing is introduced, the ANAM4 TBI battery, especially reaction time-based tests, has prognostic utility.

Patterns and perceptions of supplement use by U.S. Marines deployed to Afghanistan.

Dietary supplements are implicated in an increasing number of minor and serious adverse events, including death. A series of adverse events in deployed Marines using multiple supplements prompted medical officers to investigate the prevalence of supplement use among Marines stationed on Camp Leatherneck, Afghanistan. The investigators developed a survey to identify the types of supplements used, patterns of supplement use, reasons for taking supplements, perceived benefits from using supplements, and self-reported adverse effects. Marines were invited to complete an anonymous 17-question survey while visiting recreational and athletic facilities. A total of 329 active duty Marines completed the survey. The prevalence of supplement use was 72% for males and 42% for females (p = 0.009). Of the 12% of Marines reporting side effects, 79% were taking multiple supplements and 89% were using stimulants. Deployment was significantly associated with new supplement use (p < 0.001). Of users, 81% noted an improvement in physical performance. The majority of deployed Marines use multiple dietary supplements and perceive a high benefit. Given the high prevalence of supplement use and recent deaths associated with supplement use, recommendations are needed to guide the use of certain supplements by U.S. Marines in the deployed environment.

Cardiorespiratory, gastrointestinal, and analgesic effects of morphine sulfate in conscious healthy horses.

OBJECTIVE: To compare the cardiorespiratory, gastrointestinal, analgesic, and behavioral effects between IV and IM administration of morphine in conscious horses with no signs of pain. ANIMALS: 6 healthy adult horses. PROCEDURES: Horses received saline (0.9% NaCl) solution (IM or IV) or morphine sulfate (0.05 and 0.1 mg/kg, IM or IV) in a randomized, masked crossover study design. The following variables were measured before and for 360 minutes after drug administration: heart and respiratory rates; systolic, diastolic, and mean arterial blood pressures; rectal temperature; arterial pH and blood gas variables; intestinal motility; and response to thermal and electrical noxious stimuli. Adverse effects and horse behavior were also recorded. Plasma concentrations of morphine, morphine-3-glucuronide, and morphine-6-glucuronide were measured via liquid chromatography-mass spectrometry. RESULTS: No significant differences in any variable were evident after saline solution administration. Intravenous and IM administration of morphine resulted in minimal and short-term cardiorespiratory, intestinal motility, and behavioral changes. A decrease in gastrointestinal motility was detected 1 to 2 hours after IM administration of morphine at doses of 0.05 and 0.1 mg/kg and after IV administration of morphine at a dose of 0.1 mg/kg. Morphine administration yielded no change in any horse's response to noxious stimuli. Both morphine-3-glucuronide and morphine-6-glucuronide were detected in plasma after IV and IM administration of morphine. CONCLUSIONS AND CLINICAL RELEVANCE: Clinically relevant doses of morphine sulfate yielded minimal and short-term behavioral and intestinal motility effects in healthy horses with no signs of pain. Neither dose of morphine affected their response to a noxious stimulus.